X-Ray Dx 11/3/98
“Samurai warrior” picture=CT image
-”eyeballs”=nerve root
-”big nose”=terminal dura (cauda equina)
Paravertebral ossification differential
-ossification of ALL
-straight, thin white line
-syndesmophyte (ossified soft tissue)
Pencil thin syndesmophyte differential
-ankylosing spondylitis
-enteropathic arthritsis
-alcapnuria (okranosis)
Syndesmophyte (thick)
-exuberant syndesmophyte
-DISH, ALL is calcified
Hook shaped osteophyte
-comes from joint space
-continuous cortex
-common medullary cavity
-DJD is only option
Mixed spondyloarthropathy-multiple forms in same spine
Correlation between DISH and diabetes-13-32%
Area with DISH may move well if still have good discs
Don’t worry about fractures (due to adjustment with DISH and DJD
-be careful with the ALL syndesmophytes
Hemispherical spondylosclerosis
-half circle area of calcification
Gas in the disc space
-nuclear area=vacuum disc
-annular fibers=vacuum cleft
-more likely due to trauma (due to torn fibers)
-or degenerative change (Sharpey fibers involved)
CT-in a soft tissue window, bone is whiter
Trefoil shape of sacral canal
-due to intrusion of facets
-may be magnified by cup angle
Disc herniation (CT scan)
-compression effects-anesthesia, areflexia
-irritation, paresthesia, etc.
Intercalorie calcification (annular fibers)
-dec. disc space
Direct pressure of dural sleeve implies direct pressure from some SOL
MR cross section -PL disc bulge
SI DJD with osteophyte
Spot view-SI with DJD (white spot on bone)
-50 yr. old male-had to consider cancer also
MR-bright white lesion-SC joint
-turned out to be DJD (but could have been cancer)
-fell off a horse 10 yrs. earlier
-had arm in sling for a while
-was a painless lump
Need to be careful of painless lumps in certain age groups (make sure it’s not cancer)
Pancoast tumors-want to be careful if this is in the differential
Tiny osteophyte in finger joint
-explained swelling and pain
Peripheral join DJD
-femoral-acetabular joint
-narrow space, asymmetric, subchondral sclerosis
-frog leg shot to see from another angle
DJD-”geode” (subchondral cyst)
-osteophyte
-subchondral sclerosis
-narrowing of joint space
In cysts
-synovial fluid-some people think it intrudes on joint (intrusionist)
-flowing blood can wash away bone (inclusionist)
Actually probably a combination of blood and synovial fluid
Cysts often get larger-usually not a problem though
Knee-joint space narrower on medial side
-DJD-asymmetry in joint
Patella-osteohytes
-suprapatellar calcific bursitis
Dystrophic calcification of patellar bursa
-expect normal serum Ca, abnormal tissue
If serum Ca elevated-->metastatic
Physiologic calcification
-normal serum, normal tissue
DJD of patella
-expect medial compartment to go first
Hip-more likely to have cysts large enough to see
Bilateral degeneration in hands
-malalignment, dec. space
Symmetry-a framework for investigation
-asymmetric-joint space (intra-articular)
-comparison between hands (inter-articualr)
Gull wing deformity (right hand, distal IP joint)
If bilateral and uniform-consider RA
-need to test for RA factor
-if no RA factor
-erosive arthritis-mostly women
-abnormal chondral tissue
-abnormal chondroitin sulfate
Metacarpal-carpal joint of thumb
-bony hypertrophy, dec. joint space, bilateral, sero neg. for RA-->EOA
Lat. C-spine-unusually shaped discs
-syndesmophytes on ant.-thick ones
-DISH
DISH
-no joint space loss
-no subchondral sclerosis of endplates
-no osteophytes
-slightly dec. ROM
-greater than you would expect from the radiographs
-stiffer motion when palpated
-~32% have diabetes mellitus
-relatively common (seen monthly)
-DM is also common , so could just be overlap of the two
-difficulty swallowing (present with this chief complaint)
-not pos. on bone scan
-bad cases-ALL as large as the VB body
-little or no pain when present
-Achilles tendon, quad tendon, sup. edge of ilium, ischial tuberosity (see
“whispering”)
-1-5% of DISH pts. also have ossification of PLL
-central canal stenosis
-present with complaints
-check via MR/CT
OPLL=ossification of PLL
-PLL is only thing that ossifies
-affects Japanese men
-have compressive myelopathy
-Tx is decompressive laminectomy
HLA-B8 is foind in about 40% of DISH pts.
DISH-T8-T11 (most common), C4-C7 (second), L1-L3 (third)